Given increasing demand, advances in technology and a growing interest in addressing overdiagnosis/overtreatment, commissioners will be faced with some difficult decisions about how to derive better value for patients. This will inevitably mean stopping some services or replacing them with higher value alternatives.

This report is based on a research study which incorporated analysis of how benchmarking and identifying unwarranted variations might provide useful insights as well as qualitative work with two commissioning advisory groups.

The research study

The study explores the hypothesis that unwarranted variations are an indicator where there is clinical uncertainty about the cost effectiveness of a particular procedure or intervention and therefore could be a useful method to identify opportunities for disinvestment. The authors suggest that this can identify opportunities outside of the usual lists of “procedures of limited clinical value”. Benchmarking, available through tools such as the NHS Atlas of Variation, is an accessible method and likely to be part of routine intelligence reporting.

The study also involved qualitative research with two commissioning advisory groups and related stakeholders to explore how disinvestment is perceived and how it works in practice.

Methods

For the quantitative analysis of variations, the study team used the Hospital Episodes Statistics inpatient dataset, identifying 154 therapeutic codes, allowing for standardisation and adjustments. From this, the team identified a range of procedures with the highest national variation across PCTs, which is included in the final report.

The team also worked with the two commissioning advisory groups to perform a similar analysis for their geographies and identified a procedure, for each of the groups, which was then taken forward as a systematic review to synthesise available evidence.

For the qualitative research, the team took an ethnographic approach, attending meetings (observation) and interviewing staff and stakeholders.

Restrictive policies are often used e.g. criteria based access or “not routinely funded” policies.

Findings

The study suggests a number of barriers which prevent a systematic approach to disinvestment, including: lack of collaboration; lack of central support; and limited capacity to invest time in the required analysis of potential benefits and harms. Currently, commissioners are focused on contractual levers, rationing access and referral management as approaches; however, these may be inappropriate in some contexts and commissioners will need to consider alternative approaches to managing pathways. The report found a lack of a strategic and systematic approach to disinvestment, with significant time spent on funding requests, but little time spent on disinvestment decisions.

The conclusions recommend more openness, transparency and engagement, which depends on capacity and central support. There is often little robust evidence to inform decision making (and the authors recommend more research into interventions with high rates of variation) and where it is available, it typically reflects uncertainty and may not offer decision makers the clarity they may look for, which can lead to inertia. Where evidence is not available, this needs to be addressed through more evaluation.

The evidence base can reflect uncertainty around the efficacy of a particular intervention.

The report suggests that alongside health technology assessment, to assess new technologies, there needs to be a health technology reassessment process to evaluate technologies and interventions in use, to assess benefits and harms. However, the authors recognise that there may be less interest and less support as there can be vested interests in maintaining the status quo. There are however, opportunity costs, of investing in interventions which may not improve outcomes.

The qualitative research found varying perceptions of disinvestment and the term often has negative connotations. These different perceptions can lead to mistrust between commissioners and clinicians/providers, based on underlying assumptions; the authors note the lack of a shared language. Providers often felt uncomfortable with the lack of openness about financial drivers and felt this to be counterproductive to meaningful debate; disinvestment has often been framed as reducing waste, which clinicians felt to be unfair. Commissioners reflected the political sensitivity, suggesting that national policy makers and politicians may be raising expectations. A key recommendation centres on early engagement of all stakeholders, as opposed to involvement at the consultation stage; the process for incorporating evidence and expert opinion needs to be transparent.

Commissioners and providers often reported mistrust in discussions on disinvestment, which could be helped by more openness, engagement and transparency.

Limitations

As the researchers themselves note, the potential to use variations to spot opportunities is accessible to commissioners, through available datasets and tools such as those produced by Right Care. However, benchmarking can only offer so much insight and therefore should be used as a starting point for local debate and deeper dives. Inconsistent coding can lead to spurious conclusions and the engagement of stakeholders is essential to understand the causes of variations, system influences and the implications for the local population.

The research was conducted during the Health And Social Care Act reforms which will have caused some disruption to normal processes, so it’s possible the observed and reported behaviour wasn’t entirely typical and it may be that Clinical Commissioning Groups have developed new approaches.

Key questions for commissioners

The research findings offers some valuable lessons for commissioners. Recommendations include a focus on entire pathways, not just on the surgical intervention, working with primary and secondary care to identify opportunities and assess different approaches e.g. shared decision making, referral management or contractual levers.

The Royal College of Surgeons has taken some steps to assist this dialogue, offering commissioning guides and data tools. Additionally, it should be noted that disinvestment does not always lead to savings; the alternative pathway may cost more but offer greater cost effectiveness.

Commissioners should aim to involve stakeholders in discussion and decisions on disinvestment.

The findings suggest that whilst some of the barriers to effective disinvestment lie outside their control, commissioners are able to change processes and behaviours to facilitate local disinvestment decisions. Some questions to consider:

What is your strategic approach to disinvestment and what governance mechanisms are in place to support disinvestment decision making?

How much time is currently spent on funding requests and how much time on disinvestment? Is the balance right for your context?

What processes, if any, are currently in place to routinely identify opportunities for disinvestment? Where there are no routine processes, analysis of variations may provide a useful starting point for exploration.

How can stakeholders be engaged more actively in decision making? What needs to be put into place to facilitate involvement e.g. shared values and language?

How is evidence synthesised and used to inform decision making? How is expert opinion collected and used?

What skills and knowledge on disinvestment are available locally? What training and development is needed to support staff involved in disinvestment decision making?

Are commissioning staff aware of the various tools available?

How can process and outcome measures be meaningfully designed and monitored to assess the impact of services and interventions on patients?

Are there opportunities to work with academic and other services to evaluate the process and impact of local disinvestment decisions?

I'm Head of the Evidence Analysis team within the Strategy Unit at NHS Midlands and Lancashire Commissioning Support Unit. I'm interested in how knowledge management can support value based healthcare and evidence based decision making. I've previously worked in a range of different healthcare settings, including acute care, commissioning, health services research and medical education. More recently, I worked at NHS Evidence and NHS Institute for Innovation and Improvement.